Immediate causes of incidents
Immediate causes of incidents
Introduction
In general, immediate causes are the things that can be detected by your senses. They can be seen, heard, smelled, touched and even tasted in some cases. They are readily apparent or evident and immediately precede the contact. They need to be identified so the root causes can be identified and corrected.
Substandard acts and conditions
They are often called “unsafe acts” and “unsafe conditions”; however, we prefer to call them substandard acts and substandard conditions. Referring to them as sub-standard implies that some sort of standard exists or should exist, and that the acts and conditions are therefore controllable. Referring to them as “unsafe” acts and conditions provides few clues about how they can be controlled.
Substandard acts and conditions are signs that underlying problems exist within the system for preventing losses. As in medicine, treating symptoms often diverts attention away from identifying and correcting the root causes. “Prescription without diagnosis is malpractice”.
It is a common myth that 85% or more of all incidents are caused by substandard acts or behaviours of people. This thinking is not only misleading, it diverts attention away from identifying and solving root causes. These root causes are directly affected by the systems of work and must be addressed for long-term improvement in the SHEQ programme.
To move beyond treating symptoms, questions such as these must be asked: Why did the condition exist? What caused the substandard act to take place? Where are opportunities to correct the root causes, which led to this condition?
These questions will lead to the discovery of the root causes of the substandard acts and conditions. The answers, which they yield, will point you in the direction leading to long-term improvements in the SHEQ system.
Possible immediate causes
The table below lists typical substandard acts and conditions, which result in incidents; however, please remember that these are only signs of underlying problems in the management system.
Possible Immediate Causes
Substandard at risk acts / behaviours
1.
Following Procedures / Practices / Rules / Regulations
1-1
1-2
1-3
1-4
1-5
1-6
1-7
1-8
1-9
1-10
1-11
Deviation by individual.
Deviation by group.
Deviation by supervisor.
Operation of equipment without authority.
Improper position or posture for task.
Overexertion of physical capability.
Work or motion at improper speed.
Improper lifting.
Improper loading.
Shortcuts.
Other.
2.
Use of Equipment Tools
2-2
2-3
2-4
2-5
2-6
2-7
2-8
Improper use of equipment.
Improper use of tools.
Use of defective equipment (aware).
Use of defective tools (aware).
Improper placement of tools, equipment or materials.
Operation of equipment at improper speed.
Servicing of equipment in operation.
Other.
3.
Use of Protective Methods
3-1
3-2
3-3
3-4
3-5
3-6
3-7
3-8
3-9
Lack of knowledge of hazards present.
Personal protective equipment not used.
Improper use of proper personal protective equipment.
Servicing of energized equipment.
Equipment or materials not secured.
Disabled guards, warning systems or safety devices.
Removal of guards, warning systems or safety devices.
Personal protective equipment not available.
Other.
4.
Inattention / Lack of Awareness
4-1
4-2
4-3
4-4
4-5
4-6
4-7
4-8
4-9
Improper decision making or lack of judgement.
Distracted by other concerns.
Inattention to footing and surroundings.
Horseplay.
Acts of violence.
Failure to warn/make safe.
Use of drugs or alcohol.
Routine activity without thought.
Other.
Substandard at risk acts / behaviours
5.
Protective Systems
5-1
5-2
5-3
5-4
5-5
5-6
5-7
5-8
5-9
5-10
Inadequate guards or protective devices.
Defective guards or protective devices.
Inadequate personal protective equipment.
Defective personal protective equipment.
Inadequate warning systems.
Defective warning systems.
Inadequate isolation of process or equipment.
Inadequate safety devices.
Defective safety devices.
Other.
6.
Transportation, Equipment and Tools
6-1
6-2
6-3
6-4
6-5
6-6
6-7
6-8
6-9
6-10
Defective Vehicles, Vessels, Aircraft, Rolling Stock.
Inadequate Vehicles, Vessels, Aircraft, Rolling Stock.
Improperly prepared Vehicles, Vessels, Aircraft, Rolling Stock.
Defective equipment.
Inadequate equipment for the purpose.
Improperly prepared equipment.
Defective tools.
Inadequate tools.
Improperly prepared tools.
Other.
7.
Work Exposures to
7-1
7-2
7-3
7-4
7-5
7-6
7-7
7-8
7-9
7-10
7-11
7-12
Fire of explosion.
Noise.
Energized electrical systems.
Energized systems, other than electrical.
Radiation.
Temperature extremes.
Hazardous chemicals.
Mechanical hazards.
Clutter or debris.
Storms or acts of nature.
Slippery floors or walkways.
Other.
8.
Workplace Environment / Layout
8-1
8-2
8-3
8-4
8-5
8-6
Congestion or restricted motion.
Inadequate or excessive illumination.
Inadequate ventilation.
Unprotected height.
Inadequate workplace layout:
- Demarcation less than adequate.
- Controls less than adequate.
- Displays less than adequate.
- Labels less than adequate.
- Locations out of reach or sight.
- Conflicting information is presented.
Other
